An Unusual Presentation of Adrenocortical Carcinoma (ACC): Panic Attacks and Psychosis.

BACKGROUND Adrenocortical carcinoma (ACC) is a very rare disease, with an incidence of 1.02 per million population per year. The most commonly secreted hormone in ACC is cortisol, often presenting as a rapidly progressive Cushing syndrome (CS). We describe a case of ACC with an unusual presentation, mainly with psychiatric manifestations, including panic attacks and hallucinations. CASE REPORT A 52-year-old woman presented with episodes of acute anxiety, hallucinations, palpitations, hot flashes, gastrointestinal upset associated with paroxysmal hypertension, tachycardia, and flushing for 1 week. The initial workup was aimed at ruling out causes of acute psychosis and/or anxiety such as substance use, and organic diseases such as pheochromocytoma (PCC). Our initial suspicion of PCC was ruled out based on the negative serum and urinary metanephrines (MN) and normetanephrines (NMN). Recurrent metabolic alkalosis and hypokalemia despite fluid and potassium supplementation prompted us to work up for hyperaldosteronism. Her renin level was elevated and the aldosterone level was appropriately suppressed. Elevated cortisol, positive dexamethasone (DXM) suppression test, low adrenocorticotropic hormone (ACTH), imaging revealing an adrenal mass, and postoperative histology confirmed the diagnosis of cortisol-producing ACC. CONCLUSIONS It is essential to recognize psychiatric presentations of CS to achieve early diagnosis and prevent mortality and morbidity. Panic attacks, a common presentation of CS, can present with features mimicking pheochromocytoma (PCC), including palpitations, sweating, tachycardia, and paroxysmal hypertension. A comprehensive workup is warranted to reach a diagnosis, with a combination of hormonal levels, imaging, and histology.

A Case of Methicillin-Sensitive Staphylococcus aureus (MSSA) Prostate Abscess, Osteomyelitis, and Myositis Associated with MSSA Bacteremia in a 60-Year-Old Patient Presenting with Back Pain.

BACKGROUND Staphylococcus aureus (SA) is a rare cause of prostatic abscess. Risk factors include genito-urinary instrumentalization and immunocompromised states. Because of the lack of guidelines on the diagnosis, management, and follow-up of SA prostate abscess, the diagnosis can sometimes be challenging. Our patient was a 60-year-old man who initially presented with lower back pain and was diagnosed with a methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, prostate abscess, osteomyelitis, and myositis. CASE REPORT A 60-year-old man presented with lower back pain. He had a past medical history of incompletely treated MSSA cervical osteomyelitis with epidural abscess, alcohol use disorder, intravenous drug use (IVDU), and poorly controlled diabetes mellitus (DM). He was afebrile and hemodynamically stable. Laboratory test results revealed leukocytosis and an elevated C reactive protein (CRP). Lumbar spine magnetic resonance imaging (MRI) showed vertebral osteomyelitis and right psoas myositis. Blood cultures isolated MSSA. The patient was treated with vancomycin and piperacillin-tazobactam. On day 5, our patient reported having fever, chills, flank pain, and dysuria. Computed tomography (CT) revealed a 4.0×4.9 cm prostatic abscess. CT-guided percutaneous abscess drainage was performed, and fluid culture revealed MSSA. Both antibiotics were discontinued and cefazolin was started following sensitivities. Post-drainage pelvic ultrasound (US) showed resolution of the abscess. CONCLUSIONS This case highlights the importance of a rapid diagnosis of SA prostate abscess in patients with documented risk factors and characteristic symptoms. Timely management with antibiotics and drainage as indicated are imperative to avoid further complications from the underlying bacteremia, including sepsis and metastatic infections.

A Case of Hemophagocytic Lymphohistiocytosis (HLH) Secondary to T Cell Lymphoma and Cytomegalovirus (CMV) Infection and Complicated by Tumor Lysis Syndrome (TLS).

BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of systemic hyper-inflammation, caused by an excessive cytokine secretion, secondary to an uncontrolled proliferation of lymphocytes and macrophages, and leading to vascular endothelial injury and multi-organ failure. HLH is either primary/familial due to genetic mutations in the genes coding for the CD8+ and NK T cells cytotoxic proteins or is secondary to infection, malignancy, or autoimmune disorders. Timely diagnosis using the HLH-2004 criteria and prompt initiation of treatment for HLH is essential for the survival of affected patients. Adults with HLH have poor outcomes even with aggressive treatment. CASE REPORT Our patient was a 48-year-old man who presented with altered mental status. He was tachycardic and tachypneic, and quickly developed acute hypoxemic respiratory failure requiring mechanical ventilation. Computed tomography (CT) of the chest and abdomen showed bilateral pleural effusion, ascites, and heterogeneous splenomegaly. Laboratory workup revealed anemia, thrombocytopenia, severe hyperferritinemia, hypofibrinogenemia, and hypertriglyceridemia. Pleural fluid analysis showed a lymphocytic exudate, with T cell predominance on flow cytometry. A T cell rearrangement study of the pleural fluid was positive. Bone marrow biopsy showed histiocytes with hemophagocytic activity. The diagnosis of HLH secondary to T cell lymphoma was made, and the patient was treated with dexamethasone and etoposide. A few hours later, the patient had a cardiac arrest, and laboratory findings suggestive of tumor lysis syndrome (TLS) were discovered. The patient died of refractory shock one day later, and the cytomegalovirus (CMV) PCR result was positive during that day. CONCLUSIONS Adults with HLH have poor outcomes even with aggressive treatment. Additional focus on the management of HLH should shift towards preventing complications such as TLS. More studies should focus on post-treatment outcomes of HLH secondary to malignancy to improve the management and prognosis.